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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOP. OIFICL USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z2 D-;e <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin.; <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local Heaith Dis5rict. <br /> .TOB ADDRESS/LOCATION I I CENSUS TRACT � <br /> Owner's Name - APhone <br /> Address o e City t r <br /> Contractor's Name License # Phone �3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 b\ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout a <br />} <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Q V [--, <br /> Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: State Work Done <br /> K <br /> PUMP 'tEPAIR: / / State Work Done <br /> DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Describe Material and Procedure <br /> j I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well •construction. Within FIFTEEN DAYS <br /> after completion of my work on a neva well, I will furnish the San Joaquin Local Health District a <br /> a WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLES ._ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F FOR DEP,kRTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY ��4 <br /> DATE(��' <br /> ADDITIONAL Cd!*1ENTS: <br /> PRASE II GROUT INSPECTION PHASE III/ INAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION Br DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> -, + iill L-'rw-t 711M � <br />